NICE has introduced new criteria for appraising end of life treatments. James Raftery looks at how they might affect availability by applying them to previously refused drugs
This article examines the implications for patient care, and for the future of rationing within the NHS, of the recent decision to permit NHS patients to supplement their care by paying for medicines — mainly expensive new cancer drugs — which are not available within the NHS. The starting point is the recommendations of the Richards' Report and their implementation through new guidance issued by the DoH and NICE. Practical challenges arise from the insistence upon the 'separate' delivery of self-funded medicines, and more flexible cost-effectiveness thresholds for end of life medicines may have repercussions for other patients. While undoubtedly part of the trend towards explicit rationing, top-up fees might also represent a significant step towards regarding the NHS as a core, basic service. Finally, the issue of top-up fees is located within the broader context of current cancer research priorities and persisting health inequalities.
The paper discusses the issue of family involvement in the process of obtaining consent to treatment. Legally, doctors have a duty to inform the patient, and the patient has a right to be informed before making a decision. In this context, however, there is no requirement to involve relatives or to take into account their interests or requests. Yet, findings from in-depth interviews with NHS general practitioners presented in the paper indicate that in reality relatives have a substantial impact on the process of informed consent. Their presence may lead the doctor to provide more information to the patient and help the patient better understand the information conveyed by the doctor. Ultimately, the relatives' involvement enhances the patient's ability to make an informed decision, even though in some cases – when the relative is dominant – this may have a negative impact on the channel of communication between doctor and patient. These findings reflect a relational approach to patien